Healthcare Provider Details

I. General information

NPI: 1972595478
Provider Name (Legal Business Name): ANDREA MARISA STALLINGS MS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8851 CENTER DR SUITE 404
LA MESA CA
91942
US

IV. Provider business mailing address

3444 PRINGLE ST UNIT 9
SAN DIEGO CA
92110-1961
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-1293
  • Fax:
Mailing address:
  • Phone: 619-379-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: